In addition and especially for patients whose symptoms are either

In addition and especially for patients whose symptoms are either not controlled or selleck products became worse on therapy, other strategies may be considered. Epileptic encephalopathy is a possibility, especially in patients with severe and persistent symptoms. Can therapy with benzodiazepines, high-dose steroids or other immunosuppressant drugs be considered?17 The aetiology of nodding syndrome is still unknown. In all three countries where

nodding syndrome has been described, it has been associated with infestation by Onchocerca volvulus.1 7 18 Uganda is in its second year of twice yearly mass administration of ivermectin (an antimicrofilarial agent active only against the mirofilaria but not the adult parasite). Other strategies that target both microfiliaria and the adult worms and/or their cosymbiotic bacteria, Wolbachia, may be considered as potential specific therapy.19 20 Despite these improvements, parents reported that the majority

of the 40% of children who returned to school continued to perform poorly. There is a need to examine whether the continued poor academic performance is due to irreparable brain injury or an underlying ongoing aetiopathogenic process. To date, there are no systematic studies of cognitive function in nodding syndrome. Such studies will help define areas of functional deficits and document improvements preferably using tools that can be applied across different regions with minimal modification to allow comparison. We did not apply specific psychiatric

diagnostic tools to patients with behaviour and emotional difficulties to be able to make distinct psychiatric diagnoses. A few children with severe difficulties were attended to by the local mental health services and some were given psychotropic drugs. The majority of the 194 children in whom behaviour and emotional difficulties resolved, however, improved without psychotropic drugs but with seizure control, suggesting that in nodding syndrome some of these features may AV-951 be comorbidities of epilepsy. Wandering behaviour may be an ictal event.6 Some patients may also have benefited from the effects of sodium valproate on behaviour; in a recent case series of Ugandan children, Musisi et al21 documented improvements in some patients receiving antidepressants. Put together, these findings suggest that psychotropic drugs may be considered for some patients with nodding syndrome, especially those with severe symptoms. Study limitations First, other than head nodding, seizures in nodding syndrome may be similar to seizures in other convulsive epilepsies and over time, head nodding may cease in some patients.9 This scenario opens room for potential misclassification of disease as the current disease criteria heavily leans on clinical observations.

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